Tri State Pet Rescue 
Adoption Application
Begin Application
Your Name: *

Spouse/Partner Name:

Street Address: *

No P.O. Boxes
City, State, Zip Code: *

Home Phone:

Cell Phone:

Employer Name:

Employer Address:

Work Phone:

May we call you at work?

Are you 21 years of age or older? *

Date of Birth: *

Drivers License # and Issuing State:

Marital Status:

Housing: *

If renting, Name/Phone # of Landlord:

If renting, is a pet deposit required?

If living at home, will parents give permission for this animal?

Parent Phone:

How long at current address? *

Do you plan to move within the next 6 months? *

If so, what do you plan on doing with your pets?

How many adults in your household? *

How many children? *

Ages of children?

Number of Pets in Household: *

Specify Dog/Cat/Other:




How long owned:

Are all spayed/neutered?

Up to date on Rabies vaccinations?

Up to date on Distemper/Parvo?

Up to date on Bordetella (Kennel Cough)?

Heartworm preventative?

Flea/Tick protection?

Name of your veterinarian?


Veterinarian Phone:

May we call for a reference?

How will you keep your new pet confined to your property? *

Check all that apply

If other, please describe:

If you plan to keep your new pet outside, please describe the type of shelter you will provide:

If you have a fenced yard, describe type of fence material and height:

Do you live near a busy road or highway? *

How many hours per day will dog be left alone? *

Where will dog be left during your absence? *

Do you object to an inspection of your premises by a Tri State Pet Rescue representative? *

If yes, please state reason why:

Have you ever surrendered a pet to Tri State Pet Rescue or any other agency? *

If yes, please state reason why:

If you are applying for a specific dog, please state dog's name here:

The typical lifespan of a dog is 10-15 years. Are you willing to care for this animal for the rest of it's life? This includes, but is not limited to, providing food, water, shelter, medical care, yearly vaccinations, monthly hearworm prevention and flea/tick control? *

By submitting this application, you certify the information you have provided is accurate and complete to the best of your knowledge. You understand that Tri State Pet Rescue has the right to reclaim the animal if any information given is false or if the animal is not being properly cared for according to the adoption agreement. You authorize the release of veterinarian information related to current and past pets you have owned. This application is the property of Tri State Pet Rescue/FAMA. *

Please choose below:
Thank you for your application. A Tri State Pet Rescue representative will contact you soon.
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